Provider Demographics
NPI:1407207111
Name:SUN DERMATOLOGY LLC
Entity Type:Organization
Organization Name:SUN DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:PYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-791-5423
Mailing Address - Street 1:2101 JENKS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4511
Mailing Address - Country:US
Mailing Address - Phone:334-791-5423
Mailing Address - Fax:
Practice Address - Street 1:2101 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4511
Practice Address - Country:US
Practice Address - Phone:334-791-5423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty